Volume 9, Issue 1, 2001
Review
Outpatient Parenteral Antibiotic Treatment: the Italian model
Esposito Silvano
Though constrained by the lack of standard criteria for patient selection and well defined therapeutic protocols, the Italian model of OPAT is characterized by the home treatment of infections also of moderate severity, chiefly of the lower respiratory tract by means of broad spectrum antibiotics (chiefly beta-lactams) administered intramuscularly. The selection of patient for OPAT remains an individual decision of GPs based on the severity of infection, concomitant diseases, age of the patient, reliability of patients and family, environ- mental and social factors.
Such a model has gained broad consensus over the years from patients for different cultural reasons: first, the willingness of patients to participate in the OPAT programmes, second, the concept that home is better than hospital even when you are ill and, third, the fact that parenteral drugs are perceived as more effective than oral ones, probably in contrast with the culture and traditions of other countries (especially northern Europe) where hospitals are still considered the only proper site of care and intramuscular administration is regarded as almost unnatural.
No private or insurance reimbursement based OPAT structure exists up to now in Italy or is go. ing to be developed.
The main problems in Italy now seems to be:
-to define clear protocols and easy criteria for selection of patients enable to OPAT,
-to improve what existing by creating and/or qualifying new professionals involved with in- and outpatients (OPAT, early discharge ,medical care for special populations...).
Original article
Vascular graft infection by Staphylococcus epidermidis: efficacy of various prophylaxis protocols in an animal model
Giacometti Andrea,
Cirioni Oscar,
Ghiselli Roberto,
Moccheggiani Federico,
Riva Alessandra,
Saba Vittorio,
Scalise Giorgio
A rat model was used to investigate the efficacy of levofloxacin, cefazolin and teicoplanin in the prevention of vascular prosthetic graft infection.
Graft infections were established in the subcutaneous tissue of 300 male Wistar rats by implanta- tion of Dacron prostheses followed by topical inoculation with methicillin-susceptible and methi- cillin-resistant S. epidermidis. The study included a group without contamination, two conta- minated groups without prophylaxis, two contaminated groups with intraperitoneal levofloxacin prophylaxis (10 mg/kg), two contaminated groups with intraperitoneal cefazolin prophylaxis (30 mg/kg), two contaminated groups with intraperitoneal teicoplanin prophylaxis (10 mg/kg) and six contaminated groups with rifampin-soaked graft and intraperitoneal levofloxacin, cefazolin or te- icoplanin prophylaxis. The grafts were removed after 7 days and evaluated by quantitative culture. The efficacy of levofloxacin against the methicillin- susceptible strain did not differ from that of cefa- zolin or teicoplanin. Levofloxacin showed slight less efficacy than teicoplanin against the methicillin-resistant strain. The levofloxacin-rifampin combination proved to be similarly effective to the rifampin-teicoplanin combination and more effective than the rifampin-cefazolin combination against both strains. The rifampin-levofloxacin combination may be useful for the prevention of late-appearing vascular graft infections caused by S. epidermidis because it takes advantage of the good anti-staphylococcal activity of both drugs.
Microbial environmental surveillance in a bone marrow transplant unit
Pisano M. Barbara,
Cosentino Sofia,
Puddu Raffaella,
Puggioni Silvia,
Palmas Francesca
The aim of this study was to evaluate, after several years of application, in a bone marrow transplant (BMT) center of a Cagliari Hospital, the effectiveness of the disinfection protocol in minimizing the risk of environmentally transmitted infections. Microbial contamination of the air was evaluated every two months during normal activity using an SAS sampler. The contamination of surfaces was determined weekly, 2hrs after sanitation, 4smg disposable surface contact plates.
The results of environmental monitoring generally showed low values of microbial contamination of air and surfaces. Only two service rooms and two patient's rooms without own bathroom showed levels of microbial contamination slightly exceeding, in a few samplings, the values considered acceptable for environments at high risk of infections. From a qualitative point of view, the microrganisms isolated generally belonged to environmental species. In conclusion our study confirms the importance of microbial monitoring in the control and prevention of outbreaks of infections in BMT Units. This approach allows significant reduction in the level of contamination not only by improving cleaning procedures, but also by motivating the cleaning staff trough making them aware of their responsibilities.
Survey of disinfectant usage in a Roman policlinic: preliminary results
Leoni Valerio,
Urso Mirella,
Materazzo Fabiola,
Rossigni Angelo
The authors describe the survey that was conducted in the largest hospital in Rome. The aim was to estimate the disinfectants and chemical sterilizers employed and asses possible hazards for patients and workers arising from the use of disinfectants, together with the problem of waste disposal.
The study was conducted by means of a survey form that was distributed to 39 departments/institute in the whole hospital of which 24 (61%) responded. Overall 635 charts were collected listing 886 usage procedures and 110 formulations with 40 different active ingredients.
The disinfection fields of use were: skin(52.4%) environment (28.8%) and hospital equipment (20.8%) This study shows that a modern hospital should select very few disinfectants and prepare a handbook that can explain disinfectant usage procedures and concentrations. In the guidelines the problem of waste disposal and employee safety should also be considered.
Clonal diffusion and evolution of polymorphisms of mecA and Tn554 in methicillin-resistant Staphylococcus aureus in Italy
Campanile Floriana,
Cafiso Viviana,
Cascone Carmela,
Gianninò Viviana,
Di Marco Oriana,
Stefani Stefania
The purposes of the present study were to track the geographic spread of 69 MRSA strains in Italy recovered from 7 hospitals in four towns; to detect the clonal identities among the isolates by a combination of multiple genomic typing methods and to measure temporal trends in clonal types between 1984 and 1998. Our results showed the spread of three major clones among the MRSA isolates of 1984-1995 period: the most represented MRSA clone carried the PFGE pattern A, the mecA polymorph II and had no homology with Tn554 (II::NH::A); most of these isolates were susceptible to the macrolides ,being similar to the historically " archaic" MRSA strains; the clone typed I::E::A, carried the PFGE pattern A, the mecA polymorph I and Tn554E commonly defined as "Iberian clone"; unique clone, showing an uncommon PFGE pattern E. the mecA polymorph II and the Tn554 E (II::E::E) and were characterized by a uniform susceptibility to tetracycline and rifampin. During 1997-98 the representation of this clone increased instead of the classical “Iberian clone”. A new multi-resistant MRSA strain, carrying the PFGE pattern B (or B’), the mecA polymorph XI and Tn554 polymorph B (XI::B::B), called "Brazilian clone", increased from being absent (1984-95) to 48%. Our molecular data show an Italian MRSA "scenario" far from the common European trends and clearly documented the spread of an archaic clonal type (II::NH::A) in 1984-95, the arrival and rapid increase of Brazilian done in 1997-98 and the chronological and geographical spread of a unique (H::E::E) called "Italian clone", instead of the widely spread Iberian MRSA clone.
Case report
Transverse myelitis associated with Mycoplasma pneumoniae: a report of two cases.
Parisi Aldo,
Filice Gaetano
The authors report two cases of transverse myelitis due to Mycoplasma pneumoniae occurring during a recent acute infection due to Epstein-Barr virus (EBV). The clinical picture included weakness of the legs, bladder dysfunction, fever, headache and in one case, a mild confusional state. Magnetic Resonance Imaging (MRI) revealed a segmental edema of the lumbar tract and cerebro-spinal fluid analysis showed a mild pleocytosis and an increased level of proteins with a blood-brain barrier damage. The diagnosis of acute infection due to Mycoplasma pneumoniae was made on serological criteria.
The patients recovered completely after a 14-day course of an associated regimen with Ciprofloxacin (400 mg/day i.v.) plus prednisone (60 mg/day i.v.).
The authors emphasise the immunological disorders in the combined infection with Mycoplasma pneumoniae and EBV, supposing that an infective mononucleosis may predispose to mycoplasmic transverse myelitis.
Pathogenic role of Acinetobacter spp during HIV infection
Manfredi Roberto,
Nanetti Anna,
Valentini Roberta,
Chiodo Francesco
In order to assess the clinical role of bacterial complications due to Acinetobacter spp. during HIV disease, a retrospective survey of clinical and microbiological data of 2221 HIV-infected patients hospitalised during the past 10 years was carried out, evaluating all episodes of Acinetobacter spp. infection according to several epidemiological, clinical and therapeutic variables. Eleven patients of 2221 (0.5%) suffered from Acinetobacter spp. disease: sepsis in 5 cases, and urinary, respiratory tract disease and bacteremic pneumonia in three, two, and one patient respectively. A. calcoaceticus was responsible in 4 cases, A. lwoffii in three, and Acinetobacter spp. in the 4 remaining cases; 4 patients experienced a polymicrobial infection, and 7 had a prior diagnosis of full-blown AIDS. All patients had a severe HIV-related immunodeficiency (mean CD4+ lymphocyte count 118.2 45.3 cells/l). Compared with other localizations, sepsis was related to a lower mean CD4+ cell count (p<.001), and a more frequent occurrence of leucopenia-neutropenia (p<.005). Disease episodes diagnosed after the first 72 hours of hospitalisation (deemed no- socomial in origin), proved more frequent than community-acquired ones (9 cases versus 2), af- fected predominantly patients with AIDS and neutropenia, and were frequent1y associated with bacteremia (p<.04) The use of broad spectrum antibiotics, corticosteroids and cotrimoxazole, was recognized during the month preceding the diagnosis of Acinetobacter spp. disease, in 6, 4, and 8 cases, respectively. One patient only had an indwelling intravascular catheter, while no recent history of surgery, intensive care, or other invasive procedures was found. At in vitro su- sceptibility studies, bacterial isolates showed complete resistance to ampicillin and cephalothin, and low sensitivity to second-generation cephalosporins, while a higher susceptibility rate was revealed towards ceftazidime, netilmicin, amikacin, and quinolones, followed by cotrimoxazole and piperacillin. A prompt and appropriate antimicrobial therapy (mostly carried out with cephalosporins and aminoglycosides), led all patients to a clinical and microbiological cure within 6-1.3 days, in the absence of mortality or relapses. As opportunist pathogens with a predominant nosocomial origin, Acinetobacter spp. organisms may be responsible for an appreciable morbidity in patients with HIV disease, especially when additional risk factors (immunodeficiency, underlying diseases, and hospitalisation) are present. Notwithstanding the high drug resistance profile of the majority of isolated organisms, a timely diagnosis and a treatment based on in vitro assays, contribute to avoid recurrences and potentially life-threatening complications.
The Infections in the History of Medicine
Innovation in nineteenth century healthcare: disinfection stations
Pistacchio Eleonona
The possibility of limiting and preventing epidemics by cleansing everything that could be touched by patients, was an intuitive thought well before microbial discoveries. In accordance with the "miasmas theory", morbid substances were emanated from the bodies of the patients. A step forward took place in the 19th century with Pasteur and Koch's discoveries and progress in chemical disinfectants. The law was slow to adapt: in Italy only in 1888 was a Code drawn up to establish some "Disinfection Stations", places for the sterilisation of infectious material from patients' homes. Later, a similar home service was started for everything that was not transportable. Thus, in the case of cholera, smallpox, scarlet fever, diphtheria, typhus, tuberculosis, etc... it became possible to sterilise everything with which patients came into contact.
